lap band surgery denied by tricare

[crafty mama 0]

I just found out yesterday that tricare denied my lap band surgery. I am so sad and I don't know where to go from here. I sent in a letter of appeal yesterday as well, to try to get the ball rolling there. I really really wanted to have my surgery asap. I am over 100lbs but just barely and I have high chonlesterol and a long history of diabetes in my family but so far I don't have it yet. I wanted to avoid getting any sicker than I am already. Any advice on how to get them to approve me? I just feel like someone knock the wind out of my sails.

[Dave_NW 92]

I just found out yesterday that tricare denied my lap band surgery. I am so sad and I don't know where to go from here. I sent in a letter of appeal yesterday as well, to try to get the ball rolling there. I really really wanted to have my surgery asap. I am over 100lbs but just barely and I have high chonlesterol and a long history of diabetes in my family but so far I don't have it yet. I wanted to avoid getting any sicker than I am already. Any advice on how to get them to approve me? I just feel like someone knock the wind out of my sails.

Sorry to hear about this. Tricare is very specific about what they will and won't pay for. Their website says these are the requirements to be approved for surgery:

<LI>Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints

You may want to ask Tricare to explain just why you were turned down. If your surgeon recommends you for surgery, they must think you're a good candidate. Hope your appeal works.

Good Luck!

Dave

[YngGram 73]

Couple of factors, which TriCare? Prime is different than Standard and location makes a difference. Also I think it matters if your spouse is active or retired.

Obesity Treatment

TRICARE only covers morbid obesity surgery such as gastric bypass, gastric stapling and gastroplasty when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
• Is 200 percent or more over ideal weight for height and bone structure
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery

I was 240 lbs. , ideal is 135 . Hypertension & breast cancer in my history. We have standard and I was approved frist try. Good luck with the appeal

[GoSetReady 0]

I just found out yesterday that tricare denied my lap band surgery. I am so sad and I don't know where to go from here. I sent in a letter of appeal yesterday as well, to try to get the ball rolling there. I really really wanted to have my surgery asap. I am over 100lbs but just barely and I have high chonlesterol and a long history of diabetes in my family but so far I don't have it yet. I wanted to avoid getting any sicker than I am already. Any advice on how to get them to approve me? I just feel like someone knock the wind out of my sails.

I hope your appeal goes through. I understand your frustration. The requirements through Tricare changed on 2/14/11 to the following:

Check out the Federal Registrar to see if this may help your case. I spoke with the Tricare director in WA and was told the change was effective 2/14 but Tricare reps might not know about the change for a few months.

http://federalregister.gov/a/2011-3207

Show citation box (A) Payment for bariatric surgical procedures is determined by the requirements specified in paragraph (g)(15) of this section, and as defined in § 199.2( of this part.Show citation box

( Covered bariatric surgical procedures are payable only when the patient has completed growth (18 years of age or documentation of completion of bone growth) and has met one of the following selection criteria:Show citation box

(1) The patient has a BMI that is equal to or exceeds 40 kg/m 2 and has previously been unsuccessful with medical treatment for obesity.Show citation box

(2) The patient has a BMI of 35 to 39.9 kg/m ^[2] , has at least one high-risk co-morbid condition associated with morbid obesity, and has previously been unsuccessful with medical treatment for obesity.

[LVGirl 4]

I hope your appeal goes through. I understand your frustration. The requirements through Tricare changed on 2/14/11 to the following:

Check out the Federal Registrar to see if this may help your case. I spoke with the Tricare director in WA and was told the change was effective 2/14 but Tricare reps might not know about the change for a few months.

http://federalregister.gov/a/2011-3207

Show citation box (A) Payment for bariatric surgical procedures is determined by the requirements specified in paragraph (g)(15) of this section, and as defined in § 199.2( of this part.Show citation box

( Covered bariatric surgical procedures are payable only when the patient has completed growth (18 years of age or documentation of completion of bone growth) and has met one of the following selection criteria:Show citation box

(1) The patient has a BMI that is equal to or exceeds 40 kg/m 2 and has previously been unsuccessful with medical treatment for obesity.Show citation box

(2) The patient has a BMI of 35 to 39.9 kg/m ^[2] , has at least one high-risk co-morbid condition associated with morbid obesity, and has previously been unsuccessful with medical treatment for obesity.

I just had my surgery on 5/27 and they did not use this new formula at that time, it was still the weight and co-morbidities.

Good luck with your appeal! Tricare is one of the easier insurance companies to deal with but they are very strict about their requirements.